Rochio Perez v IWCC

The Commission entered an award which included an order to pay medical expenses. At trial, the employer submitted medical expenses paid by Cigna, petitioner’s husband’s carrier, plus certain co-payments. The parties stipulated to the fee schedule amounts, with the caveat that the employer disputed that the fee schedule was the appropriate basis for calculating medical. The circuit court remanded, instructing the Commission to calculate the amount owed. The Commission found that the maximum amount of medical expenses were the out-of-pocket payments and the sums paid by Cigna. On appeal, petitioner argued that only when the employer negotiates the rate with its own carrier does the ‘negotiated rate’ provision apply; the employer argued that the plain language of the statute makes the employer liable only for the medical expenses actually paid. Section 8(a) states, “The employer shall…pay the negotiated rate…or the lesser of the health care provider’s actual charges or according to a fee schedule.” The Court noted that the statute requires the employer to pay “the negotiated rate,” and cited Commission guidelines and the Illinois Administrative Code which clarify that the fee schedule neither precludes a privately negotiated rate between a carrier and a provider nor limits a negotiated rate to the employer’s carrier. The employer’s liability is limited to reimbursing petitioner the amount actually paid. An award beyond that would result in a windfall to petitioner.